Dental Plan Quick Facts and Quick Link - Login- Home … Plan Quick Facts and Quick Link ... THIS CHAPTER U.S. Salaried & Full ... • Discounts on Cosmetic Dentistry from MetLife

Dental Plan Quick Facts and Quick Link

U.S. SALARIED & FULL-TIME HOURLY ASSOCIATES TO ENROLL, GO TO WWW.LIVETHEORANGELIFE.COM; FOR HELP, CALL 1-800-555-4954

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U.S. Salaried & Full-Time Hourly Associates

Cool Dental Plan Features• FREE Dental Check-Ups. Two cleanings and checkups each calendar year arefree (subject to your option’s maximum annual benefit) with no deductible if you usea dentist in the MetLife PDP network.

• 15% to 45% Discount for Care from MetLife PDP Dentists. You canuse any dentist; however, you will pay less if you use a MetLife network dentist.

• Discounts on Cosmetic Dentistry from MetLife PDP Dentists.

When Do I Enroll in Dental Coverage?• New Associates Enrolling for the First Time: Before your 91st day ofemployment (29th day for Hawaii associates).

• All Other Associates: During annual enrollment and when you have a life event.

Quick Links to FrequentlyUsed Dental Plan Info

• I want to find a MetLife PDP dentist

• My child needs braces

• What’s covered under the plan?

• What’s not covered under the plan?

Your Dental Plan OptionsMetLife $500 Max MetLife $1,000 Max MetLife $2,000 Max

* You pay this percentage of the PDP (Preferred Dentist Program) charge if you use a MetLife dentist or the reasonable and customary charge if youuse a non-MetLife dentist.

MetLife $500 Max MetLife $1,000 Max MetLife $2,000 Max

Covers Preventive Care 100%* 100%* 100%*

Covers Restorative Care (fillings, oralsurgery, root canals, periodontics)

Yes, you pay 30%* Yes, you pay 25%* Yes, you pay 20%*

Covers Major Care (crowns, bridges) No Yes, you pay 60%* Yes, you pay 50%*

Covers Orthodontia (braces) No Yes, you pay 50%* Yes, you pay 50%*

Per-biweekly Paycheck PayrollDeduction—Associate-only Coverage

$6.19 $12.91 $16.00

A Quick Look at the Dental Plan

Dental PlanContacts

Dental PlanDetails

1 2 3

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U.S. Salaried & Full-Time Hourly Associates

U.S. MEDICAL (EXCEPT HAWAII)CHAPTER CONTENTS

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for BENEFITS SUMMARY

MAIN MENU for THIS CHAPTER

40 Contacting Your Medical Plan40 The Medical Plans41 Types of Medical Plans Available42 Healthy Living Credit42 Tobacco-Free Medical Plan Payroll Deduction 42 The 24/7 Care Plan43 PPO Plans43 Out-of-Area Plans44 How the PPO and OOA Plans Work45 Using PPO In-Network Providers46 Using Out-of-Network Providers

(Excluding Dialysis)

48 Medical Plan Programs: Anthem Blue Cross Blue Shield Programs

50 Benefit Coverage Charts for the PPO and OOA Plans

60 Medical Plan Programs: Cigna Programs61 What’s Covered for the Anthem BCBS and

Cigna Plans72 What the Plans Do Not Cover: Anthem BCBS

and Cigna75 The Prescription Drug Program for the PPO

and OOA Plans77 CVS Caremark Gold PPO and Silver Plus PPO

Prescription Drug Coverage

81 The High Deductible Health Plans85 Benefit Coverage Charts for the HDHPs96 HMO Plans97 Benefit Coverage Charts for the Kaiser

Permanente HMOs112 General Information About the Medical Plans116 Choosing Your Health Care and Your

Providers116 Important Terms


U.S. Salaried and Full-Time Hourly Associates

DENTALCHAPTER CONTENTS

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172 Dental Plan Options172 Coverage Categories172 How the Dental Plan Options Work173 Maximum Benefits174 Special Rule for Orthodontia:Maximum Lifetime

Orthodontia Benefit When Treatment Begins AppliesThroughout Orthodontia Treatment

174 Selecting a MetLife PDP Dentist174 Scheduling Appointments with Your MetLife PDP

Dentist174 Pretreatment Estimate of Benefits174 Pretreatment Estimate of Benefits Does Not

Guarantee Payment174 The Alternate Benefit Provision Allows for Suitable

Dental Treatment174 Filing Claims for Out-of-Network Services175 Limitations175 Changing Your Dental Option175 Benefits for In-Network Services175 Benefits for Out-of-Network Services175 Examples of How the Plan Pays Benefits176 What’s Covered 176 Preventive and Diagnostic

176 Basic Restorative176 Major Restorative178 What’s Not Covered179 Coordinating Benefits with Other Plans179 How Benefits Are Paid Through COB 180 Right to Recover Payment180 Subrogation180 COBRA (Continuing Coverage After Termination)180 Appealing a Denied or Reduced Claim


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Get the Most Value from Your Plan




Dental Plan OptionsThe Dental Plan offers you three dental options:

• MetLife $500 Max—covers only preventive andbasic restorative care

• MetLife $1,000 Max—high level of coverageincluding orthodontia

• MetLife $2,000 Max—highest level of cover-age including orthodontia

Coverage CategoriesYou may select one of four coverage categories for the dental plan options:

• associate only

• associate + spouse

• associate + child(ren)

• associate + family (children and spouse)

How the Dental Plan Options WorkAll three dental options are MetLife Preferred DentistProgram (PDP) plans that let you use any dentist youwant, but offer negotiated discounts when you go to a MetLife PDP network dentist. Your dental options provide you with comprehensive dental coverage forthe majority of preventive, diagnostic and basicdental services, but vary in deductibles, maximum benefits, coinsurance and coverage of certain benefits.

All of the dental options offer:

• Preventive dental care covered at 100%.Dental cleanings and checkups are covered at no cost if you use a dentist in the MetLife PDP(Preferred Dentist Program) network—you don’thave to meet the deductible for preventive carebenefits to begin. All dental benefits—includingpreventive care benefits—are subject to the per-covered individual annual maximum benefitthat applies to your dental option.

• Lower costs when you go to MetLife PDPnetwork dentist. You can use any dentist; how-ever, you will pay less if you use a MetLife PDPnetwork dentist because PDP network negotiatedfees typically range from 15% to 45% less thanaverage fees for the same or similar servicescharged by dentists in your area. In addition,MetLife PDP dentists have agreed to acceptMetLife’s negotiated fees as payment in full forservices performed (subject to any deductibles,co-payments, coinsurance, exclusions and benefitmaximums).

• Access to large network of providers. Tofind a MetLife PDP network dentist near you, go towww.metlife.com/dental. If your dentist is notpart of the network, he or she can apply tobecome a MetLife PDP network dentist by goingto www.metdental.com, a website for den-tists only or calling 1-877-638-3379.

• Same coverage for non-network dentists.You’ll have the same level of coverage—the same

What do you need? Find it here...

Find a MetLife PDP dentist Go to www.metlife.com/dental and click “Find a PDP dentist” or call 1-800-638-9909

Get a claim form for out-of-network services Go to www.metlife.com/dental to download a claim form or call 1-800-638-9909

Submit a claim form Take a claim form with you to your dentist. Mail to: MetLifeP.O. Box 981282El Paso, TX 79998-1282

• Track your claims online and receive e-mail alerts when a claim has been processed• Find out the approximate in-network (PDP) fees and out-of-network fees in your area for many dental services

Log into www.livetheorangelife.com or go to www.metlife.com/dentaland set up a user ID and password.

http://www.metlife.com/dental





http://www.metdental.com


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deductible, coinsurance and annual maximum—for dental services regardless of whether you use a MetLife PDP network or non-network dentist.However, when you use a MetLife PDP network den-tist, you’ll pay the negotiated fee, which is typically15% to 45% lower than non-network dentists’ fees.For out-of-network charges, you pay any amountabove the reasonable and customary charge.

• MetLife discounts on cosmetic dentistryand other non-covered dental services.You’ll receive the MetLife PDP dentist negotiatedrate on cosmetic procedures and other servicesnot covered by the dental options when you use a PDP dentist. You also will continue to receivethe negotiated rate after you have reached yourannual maximum benefit.

The MetLife $500 Max option covers only preventive and basic restorative care and offers a lower payroll deduction. This option is designed to encourage good dental health for associates and covered family members that may need only preventive and basic restorative dental services. This option has no coverage for major services or orthodontia. Preventive care and diagnostic servicesare covered at 100% when you use a MetLife PDP net-work dentist or covered at 100% of the reasonable andcustomary charge for non-network dentists. SeeWhat’s Covered, Preventive and Diagnostic later inthis chapter for a list of covered services. Basic restora-tive dental services are subject to the deductible andcoinsurance. All dental benefits—including preventivecare benefits—are subject to the annual maximumbenefit. This option has an annual maximum benefitof $500 per covered individual.

The MetLife $1,000 Max option covers preven-

tive, basic restorative and major restorative care aswell as orthodontia for covered dependent childrenunder age 19 with a payroll deduction that is higherthan the MetLife $500 Max option. Preventive careand diagnostic services are covered at 100% whenyou use a MetLife PDP network dentist or covered at100% of the reasonable and customary charge fornon-network dentists. See What’s Covered,Preventive and Diagnostic later in this chapter for alist of covered services. Basic and major restorativedental services and orthodontia are subject to thedeductible and coinsurance. All preventive/diagnosticand basic and major restorative dental benefits aresubject to the annual maximum benefit. This optionhas an annual maximum benefit of $1,000 per coveredindividual and a separate lifetime orthodontia maxi-mum benefit of $750.

The MetLife $2,000 Max option covers preven-tive, basic restorative and major restorative care aswell as orthodontia for covered dependent childrenunder age 19 and has the highest level of coveragewith the highest payroll deduction. Preventive careand diagnostic services are covered at 100% whenyou use a MetLife PDP network dentist or coveredat 100% of the reasonable and customary chargefor non-network dentists. See What’s Covered,Preventive and Diagnostic later in this chapter fora list of covered services. Basic and major restora-tive dental services and orthodontia are subject to the deductible and coinsurance. All preventive/diagnostic and basic and major restorative dental benefits are subject to the annual maximum benefit.This option has an annual maximum benefit of$2,000 per covered individual and a separate lifetime orthodontia maximum benefit of $1,500.

See What’s Covered for complete information onthe services covered under the options.

Maximum BenefitsEach Dental Plan option pays a maximum annualbenefit for you and each of your covered familymembers as follows:

• MetLife $500 Max—$500 for each covered individual

• MetLife $1,000 Max—$1,000 for each coveredindividual

• MetLife $2,000 Max—$2,000 for each coveredindividual

All preventive/diagnostic and basic and majorrestorative dental benefits are subject to the annual maximum benefit.

Orthodontia has a separate lifetime maximum, as follows:

• MetLife $500 Max—No orthodontia coverage

• MetLife $1,000 Max—$750 lifetime maximum for each covered dependent child

• MetLife $2,000 Max—$1,500 lifetime maxi-mum for each covered dependent child

The maximum is based on orthodontic services andprocedures, whether in-network or out-of-network.Orthodontic services are available only for yourchild(ren) under age 19.


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Special Rule for Orthodontia:Maximum Lifetime Orthodontia Benefit When Treatment BeginsApplies Throughout OrthodontiaTreatmentThe lifetime maximum orthodontia benefit that willapply is based on the option in which the covereddependent child is enrolled when orthodontia servic-es began. The maximum orthodontia benefit will notchange throughout that dependent’s orthodontiatreatment regardless of the option chosen in subse-quent years.

For example, if you are enrolled in the $500 Maxoption when orthodontia treatment begins, no orthodontia benefits are paid for any orthodontiatreatment even if a benefit option is chosen in sub-sequent years that covers orthodontia treatment. Ifyou are enrolled in the $1,000 Max option when theorthodontia treatment begins, the $750 lifetime maxi-mum benefit will apply throughout the orthodontiatreatment regardless of whether you enroll in the$2,000 Max option or $500 Max option in subse-quent years.

Selecting a MetLife PDP DentistA MetLife PDP dentist is a general dentist or specialist who has agreed to accept MetLife’snegotiated fees as payment in full for services provided to plan participants. PDP fees typicallyrange from 15-45% below the average feescharged in a dentist’s community for the same or substantially similar services.

To get a list of participating MetLife PDP dentists:

• Go to www.metlife.com/dental, and click “Find a

PDP dentist”; or

• Call 1-800-638-9909 to have a list faxed or mailedto you.

If your current dentist does not participate in theMetLife PDP network and you’d like to encouragehim or her to apply, tell your dentist to go towww.metdental.com, or call 1-877-638-3379 for an application. The website and phone number aredesigned for use by dental professionals only.

Scheduling Appointments with Your MetLife PDP DentistTo set up an appointment with your MetLife PDPdentist:

• Confirm with MetLife that the specific provider and location is participating

• Call the dental office you selected.

Pretreatment Estimate of BenefitsWhenever extensive dental work is proposedinvolving charges of $300 or more, your dentist can request a Pretreatment Estimate of Benefits from the Dental Plan. Your dentist should submit a detailed description of planned treatment andexpected charges, including those for diagnostic x-rays, before dental work is started. If there is a major change in the treatment plan, a revisedplan should be sent to your dental claims office.

After reviewing the description of the planned treatment and expected charges, the Dental Plan will determine the services the Dental Plan maycover and advise your dentist.

Pretreatment Estimate of Benefits Does Not Guarantee PaymentThe estimate of benefits payable may change basedon the benefits, if any, for which a person qualifies atthe time services are completed. You must provideproof on or after the date the dental service isreceived before the Dental Plan will pay benefits.

The Alternate Benefit Provision Allows for Suitable Dental TreatmentWhen more than one dental service could providesuitable treatment based on common dental standards, MetLife will determine the dental serviceon which benefits will be based and the expensesthat will be considered as covered expenses.Benefits will be provided for treatment you receive in accordance with accepted dental standards foradequate and appropriate care.

You and your dental provider are free to apply thisbenefit payment to the treatment of your choice; however, you are responsible for any expenses thatexceed covered expenses. To avoid any surprises,use the Pretreatment Estimate of Benefits process sothat you and your dentist know in advance what theDental Plan will cover before any treatment begins.

Filing Claims for Out-of-NetworkServicesYour dentist may file your claims for you, whichmeans you have little or no paperwork. Bring a claim form with you to your appointment. If you need a claim form, you can find one online atwww.metlife.com/dental, or request one by calling1-800-638-9909. You don’t have to speak with a liverepresentative to order a claim form—the MetLife


http://www.metdental.com



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automated voice response system is available 24hours a day, 7 days a week.

If your dentist does not file claim forms for you, you must complete a claim form and send it to:

MetLife Dental ClaimsP.O. Box 981282El Paso, TX 79998-1282

Be sure to fill out a separate form for each coveredfamily member, even if more than one family member visited the same dentist on the same day. You can include more than one bill (with thesame or different dates) on a single claim form if all expenses are for the same family member.

If you or a covered family member are covered underanother employer’s group health plan that is the pri-mary payer of dental benefits, submit your claim to thatplan first. After you receive payment, send a copy of theexplanation of benefits along with copies of the item-ized bills to MetLife for processing. See CoordinatingBenefits with Other Plans in this chapter for moredetails on coordinating benefits with other plans.

LimitationsYou should file all claims within 12 months of thedate services are provided. The Dental Plan doesnot consider a claim form until the claims officereceives all required information relating to theservice or benefit provided. Claims filed more than12 months following the date services were providedmay not be eligible for benefits.

If you have questions about any of the MetLife dental options, call MetLife at 1-800-638-9909 andfollow instructions to speak to a representative.

Changing Your Dental OptionYou may change your dental option only duringAnnual Enrollment or when you have a qualifiedchange in status. See the Life Events chapter formore information.

Benefits for In-NetworkServicesPayment for in-network services under each of thedental options is limited to the PDP negotiated charge.The PDP negotiated charge refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any deductibles, copayments, coinsurance, exclusions and benefitmaximums. You are responsible for paying thedeductible and any other charges that the Dental Plandoes not cover.

Benefits for Out-of-NetworkServicesPayment of benefits for out-of-network servicesunder each of the dental options is limited to thereasonable and customary (R&C) allowance. Youare responsible for charges above R&C. Thedeductible, annual maximum and orthodontia lifetime maximum are combined for all in-networkand out-of-network procedures and services.

Certain limitations and exclusions apply to all three dental options for both in-network and out-of-network services. For further explanation of your dental coverage, call MetLife at 1-800-638-9909.

Examples of How the Plan Pays BenefitsHere are some examples of how the MetLife dentaloptions pay benefits when you go in-network or out-of-network. These examples assume that youhave met your deductible.

Example A: You are enrolled in MetLife $1,000 maximum option and go to your dentist for a filling (a basic restorative service):

• the in-network MetLife PDP negotiated fee is $245

• the out-of-network R&C cost is $400

• the dentist’s usual fee is $475

In-NetworkWhen you receive care from a participating PDP dentist

PDP fee $245.00

$1,000 MetLife Max dental optionpays: 75% x $245 PDP fee

- $183.75

Your out-of-pocket cost $61.25

Out-of-NetworkWhen you receive care from a non-participating dentist

Dentist’s usual fee $475.00

$1,000 MetLife Max dental optionpays: 75% x $400 R&C fee

$300.00



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Example B: You are enrolled in MetLife $2,000maximum option and go to your dentist for a crown (a major restorative service):

• the in-network MetLife PDP negotiated fee is $375

• the out-of-network R&C cost is $500

• the dentist’s usual fee is $600

What’s Covered Here is a list of primary covered services and limitations under each of the dental options.

Preventive and Diagnostic• oral exams twice per calendar year

• full mouth or panoramic x-rays once every 60 months

• cleaning of teeth (oral prophylaxis), twice per calendar year

• bitewing x-rays, one set in a calendar year foradults and children

• topical fluoride treatment for a child under age 19, twice per calendar year

• intraoral-periapical and extraoral x-rays

• pulp vitality and bacteriological studies for determination of bacteriologic agents

• diagnostic cast, twice per calendar year

• emergency palliative treatment to relieve tooth pain

• space maintainers for a covered child under age 14once per location

• Sealants for a child under age 19, once per toothevery five years

Basic Restorative• amalgam or resin fillings limited to once per 24-month period on the same tooth and surface

• consultations, but not more than once in a 12-month period

• root canal treatment, but not more than once in any 24-month period for the same tooth

• periodontal scaling and root planing, but not morethan once per quadrant in any 24-month period

• simple extractions

• periodontal maintenance where periodontal treatment(including scaling, root planing and periodontal surgery such as osseous surgery) has been per-formed. Periodontal maintenance is limited to fourtimes in any year less the number of teeth clean-ings received during the current calendar year

• pulp capping (excluding final restoration) and therapeutic pulpotomy (excluding final restoration)

• pulp therapy and apexification/recalcification

• re-cementing of cast restorations or dentures

• simple repairs of cast restorations or denture

• occlusal adjustments, once per 12 months

Major Restorative• general anesthesia or intravenous sedation in connection with oral surgery, extractions or othercovered services, when anesthesia is determinedas necessary in accordance with generally accepted dental standards

• initial installation of full or partial dentures or implants once per 84 months:

—when needed to replace congenitally missingteeth; or

—when needed to replace natural teeth that are lost while you or a dependent is covered underthe dental plan

• replacement of a non-serviceable denture if suchdenture was installed more than five years prior to replacement

• replacement of an immediate, temporary full denture with a permanent full denture if the immediate, temporary full denture cannot be made permanent and such replacement is done within 12 months of the installation of the immediate, temporary full denture

• relinings and rebasings of existing removable dentures:

—if at least six months have passed since the installation of the existing removable denture; and

—not more than once in any 36 month period—adjustments of dentures, if at least six monthshave passed since the installation of the denture

In-NetworkWhen you receive care from a participating PDP dentist

PDP fee $375.00

$2,000 MetLife Max dental optionpays: 50% x $375 PDP fee

- $187.50


Out-of-NetworkWhen you receive care from a non-participating dentist

Dentist’s usual fee $600.00

$2,000 MetLife Max dental optionpays: 50% x $500 R&C fee

$250.00



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MetLife $500 Max MetLife $1,000 Max MetLife $2,000 Max

Dental Services In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible (individual/family)

$25/$75 $25/$75 $50/$150 $50/$150 $50/$150 $50/$150

Annual Maximum Benefit1

(per covered individual)$500 $500 $1,000 $1,000 $2,000 $2,000

Preventive and Diagnostic Care(deductible does not apply)

Covered at 100% Covered at 100%2 Covered at 100% Covered at 100%2 Covered at 100% Covered at 100%2

Basic Restorative Care (fillings, root canals)

You pay 30% You pay 30%2 You pay 25% You pay 25%2 You pay 20% You pay 20%2

Major Restorative Care (bridges, dentures, crowns)

No coverage No coverage You pay 60% You pay 60%2 You pay 50% You pay 50%2

Orthodontia No coverage No coverage 50% up to $750 lifetime maximumper covered depend-ent child

50%2 up to $750 lifetime maximum percovered dependent child

50% up to $1,500 lifetime maximum percovered dependent child

50%2 up to $1,500 lifetime maximum percovered dependentchild

1 All preventive/diagnostic and basic and restorative dental benefits are subject to the annual maximum benefit.2 Plan pays this percentage of the reasonable and customary (R&C) charge if you use a non-MetLife dentist.

What’s Covered Under the PlanThe following charts summarize services and costs under the MetLife dental options. For more information, see What’s Covered and What’s Not Covered.


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• initial installation of cast restorations but onlywhen the tooth is fractured or has major decaythat cannot be restored with regular filling

• replacement of any cast restoration with the sameor a different type of cast restoration but no morethan one replacement for the same tooth within 84consecutive months of a prior replacement

• prefabricated stainless steel crown or prefabricatedresin crown, but no more than one replacement for the same tooth surface within 84 months

• crowns, inlays and gold fillings to restore teeth, but only when the tooth is fractured or has majordecay that cannot be restored with regular fillingsonce per 84 months per tooth

• core buildup, but no more than once per tooth in a period of 84 months

• posts and cores, but no more than once per tooth in a period of 84 months

• labial veneers, but no more than once per tooth in a period of 84 months

• oral surgery except as mentioned elsewhere inthis chapter

• periodontal surgery, including gingivectomy, gingivoplasty, gingival curettage and osseous surgery, but no more than one surgical procedureper quadrant in any 36-month period

• surgical extractions

• implants, but no more than once for the sametooth position in an 84-month period

• repair of implants, but not more than once in a 12-month period

• implant supported prosthetics, but no more thanonce for the same tooth position in an 84-monthperiod

• Occlusal guard which typically treats the effects of bruxism or grinding of teeth and other occlusal factors

What’s Not CoveredThe Dental Plan will not reimburse you for expensesrelating to the following:

• services which are not dentally necessary, thosewhich do not meet generally accepted standardsof care for treating the particular dental condition,or which are deemed experimental in nature

• services for which you would not be required topay in the absence of dental coverage

• services or supplies received by you or your covered family member before the dental coverage starts for that person

• services which are neither performed nor prescribedby a dentist except for those services of a licenseddental hygienist which are supervised and billed by a dentist and which are for:

—scaling and polishing of teeth; or—fluoride treatments

• services which are primarily cosmetic, unlessrequired for the treatment or correction of a congenital defect of a newborn child

• services or appliances which restore or alterocclusion or vertical dimension

• restoration of tooth structure damaged by attrition,abrasion or erosion unless caused by disease

• restorations or appliances used for the purpose of periodontal splinting

• counseling or instruction about oral hygiene,plaque control, nutrition and tobacco

• personal supplies or devices including, but not limited to: water piks, toothbrushes or dental floss

• initial installation of a denture or implant to replaceone or more teeth which were missing beforesuch person was insured for dental Insurance,except for congenitally missing teeth

• decoration or inscription of any tooth, device,appliance, crown or other dental work

• missed appointments

• services:

—covered under any workers' compensation oroccupational disease law;

—covered under any employer liability law;—for which the employer of the person receivingsuch services is not required to pay; or

—received at a facility maintained by theCompany, labor union, mutual benefit association or VA hospital

• services covered under other coverage providedby the Company

• temporary or provisional restorations

• temporary or provisional appliances

• prescription drugs

• services for which the submitted documentationindicates a poor prognosis


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• the following when charged by the dentist on aseparate basis:

• claim form completion;

• infection control such as gloves, masks and sterilization of supplies; or

• local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide

• dental services arising out of accidental injury to theteeth and supporting structures, except for injuriesto the teeth due to chewing or biting of food

• caries susceptibility tests

• sedative fillings

• local chemotherapeutic agents

• modification of removable prosthodontic and other removable prosthetic services

• injections of therapeutic drugs

• application of desensitizing agents

• precision attachments associated with fixed andremovable prostheses, except when the precisionattachment is related to implant prosthetics

• adjustment of a denture made within six monthsafter installation by the same dentist whoinstalled it

• duplicate prosthetic devices or appliances

• replacement of a lost or stolen appliance, castrestoration or denture

• repair or replacement of an orthodontic device

• diagnosis and treatment of temporomandibularjoint disorders

• intra- and extra-oral photographic images

• fixed and removable appliances for correction ofharmful habits

Coordinating Benefits with Other PlansIf you or a covered family member is participating inthis Dental Plan and is also covered under anotheremployer’s group health/dental plan, MetLife will coordinate coverage with that plan. Coordination ofbenefits (COB) is the process used to determine howclaims for eligible Dental Plan expenses should bepaid when you and a covered family member are cov-ered under two or more dental plans—for example, ifyou and your spouse (or same sex domestic partner)both work and are covered by each other’s employer-provided dental plan. The term “plan” refers to:

• a group insurance plan

• an HMO

• a blanket plan

• uninsured arrangements of group or group type coverage

• a group practice plan

• a group service plan

• a group prepayment plan

• any other plan that covers people as a group

• motor vehicle No Fault coverage if the coverage is required by law

• any other coverage required or provided by anylaw or any governmental program, exceptMedicaid

• Each plan or part of a plan which has the right to coordinate benefits will be considered a separate plan.

Coordination of benefits applies only when theDental Plan is the secondary plan. If the Dental Planis the primary plan (for example, if the expense wasincurred by you, as a Company associate), COBdoes not apply.

How Benefits Are Paid Through COB When the Dental Plan is the secondary plan, thetotal amount payable under the Dental Plan, whenadded to the amount or value of the benefits or services provided by all other plans, will not exceedthe amount or value of the allowable expense whichis incurred. In no event will the amount the DentalPlan pays be more than the Dental Plan would pay if there were no other plan.

When the Home Depot Dental Plan is secondary,the Home Depot Dental Plan will pay whatever is lower:

• The Home Depot Dental Plan’s normal liability; or

• The part of the allowable expenses that were notpaid by the primary plan (the remaining balance).If the reasonable and customary charge amount is different for the Home Depot Dental Plan andthe other plan, the higher amount of reasonableand customary charge will be used as the COB allowable expense to calculate benefits.


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The allowable expense is any necessary, reasonable, and customary service or expense,including deductibles or coinsurance, covered—in whole or in part—by any one of the plans thatcover the person for whom claim is made. Whenthe benefits are in the form of services, the reasonable cash value of each service is the allowable expense and is a benefit paid. The “reasonable cash value” is an amount which a duly licensed provider of dental care services usually charges patients and which is within the range of fees usually charged for the sameservice by other dental care providers located within the immediate geographic area where thedental care service is rendered under similar orcomparable circumstances.

If you have any questions about the COB rules forthe Dental Plan, call MetLife at 1-800-638-9909.

Right to Recover PaymentIf the Dental Plan makes a payment by mistake, thePlan has the right to recover the amount of the over-payment from any person, insurance company orother organization to whom the payment was made.

SubrogationThere is no subrogation provision within the DentalPlan. Subrogation is the right of the insurance com-pany to recoup benefits paid to a participant throughlegal suit, if the action causing the disability andsubsequent dental expenses was the fault ofanother individual.

COBRA (Continuing Coverage After Termination)Federal law requires that you and your eligibledependents be offered the opportunity to purchase a temporary extension of coverage under the DentalPlan at group rates in certain instances where coverage under the Dental Plan would otherwiseend. This coverage is referred to as COBRA coverage. For more information, see the COBRA Coverage chapter.

Appealing a Denied or Reduced ClaimFor information on appealing a denied or reducedclaim, see the Claims and Appeals chapter.


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When you (the The Home Depot associate) are the patient… The Home Depot Dental Plan is the primary plan.

When your spouse is the patient… His or her plan is primary and the The Home Depot Dental Plan is secondary.

When your child is the patient… The “birthday” rule is followed. This means that when both plans covering your child follow the birthdayrule, the plan of the parent whose birthday occurs earlier in the year (regardless of the ages of theparents) is primary for the child. The birthday rule is an insurance industry standard.

If one of the plans is issued out of the state whose laws govern this policy and determines the order ofbenefits based upon the gender of the parent, the plan with the gender rules shall determine the orderof benefits.

If you are legally separated or divorced (or were never married)…benefits for a child will be determined in this order:

If a court decree states that one parent is responsible for the child’s healthcare expenses or healthcoverage and the plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge. The primary plan is determined in this order:

The plan of the parent with custody of the child.

The plan of the spouse of the parent with custody of the child.

The plan of the parent not having custody of the child.

The plan of the spouse of the parent not having custody of the child.

If the above rules do not establish the order… The plan covering the claimant for the longest period of time will be primary except:

The plan covering the claimant as an active associate is primary over a plan covering the claimant asa laid-off or retired associate. If the other plan does not have this rule, it will not apply.

The plan covering the claimant as an active participant is primary over a plan covering the claimantunder a right of continuation provided by federal or state law. If the other plan does not have this rule,it will not apply.

Which Plan is the Primary Plan When Coordination of Benefits Applies?


Documents

Dental Plan Quick Facts and Quick Link - Login- Home … Plan Quick Facts and Quick Link ... THIS CHAPTER U.S. Salaried & Full ... • Discounts on Cosmetic Dentistry from MetLife